Ask the Expert: Cornell Fertility Specialist Dr. David Reichman

August 24, 2014

When you were younger, you spent a lot of time and energy trying NOT to get pregnant. But now that the time is right, what if it’s not happening as quickly as you hoped? Or what if you are in your mid- thirties and still haven’t met Mr. or Mrs. Right, or this just isn’t the time for a baby?

This is where a fertility specialist called a Reproductive Endocrinologist (RE) comes in. I’m excited to have had the chance to interview Dr. David Reichman of The Center for Reproductive Medicine at Weill Cornell’s Tribeca office. Dr. Reichman not only has an impressive bio (click here to read), but strikes me as a warm and compassionate person who is genuinely excited about his work and cares about his patients. He wants his patients to understand their treatments- so much so, that Dr. Reichman has a flat screen TV connected to his office’s computer in order to pull up pictures and diagrams, more effectively explaining procedures, medications and statistics (I know I always learn more easily with pictures). Why don’t all doctors do that?

Read the interview below for discussion on when to seek help from an RE and what treatment options are available before IVF. Also, learn about which simple changes can impact your fertility in a big way, when to consider freezing your eggs and what to expect when transitioning off the pill.

At what point should I seek help from a fertility specialist, as opposed to working with my gynecologist?

The time to see a fertility specialist is different for everyone. In general, we define “infertility” as not having conceived after 1 year of trying. For women 35 or over, infertility is defined as 6 months of trying, and that is generally when we would recommend someone at that age come in for an evaluation. That assumes, however, that the woman is getting regular monthly periods, and that the male partner hasn’t ever had any testicular issues or medications, like chemotherapy, that could affect his sperm production. For those patients, earlier evaluation is recommended. A few other things which greatly increase the risk of infertility are former infections with STDs like gonorrhea/chlamydia, ruptured appendix, or prior complicated abdominal surgery; these things increase the chances that the fallopian tubes are not open.

The question as to whether to go to a fertility specialist versus a gynecologist is a tough one for me to answer, since I’m biased (as a fertility specialist). There is a lot of variability in terms of how much general OB/GYNs know about fertility, since this isn’t a focus of most OB/GYN residency programs. There are some generalists that are really quite good, and others that are less so; I frequently encounter patients who have had unnecessary testing, testing done incorrectly, or otherwise sub-optimal treatment. If you’re on the younger side, have a good relationship with your OB/GYN generalist, and just need help ovulating, you’re probably ok with your gynecologist. Otherwise, my bias would be you’re better off seeing someone who thinks about and focuses on fertility all day long, every day of the week.

What treatment options for fertility are available before committing to IVF?

A lot. Patients often fear that they will be told to do IVF right away if they see a reproductive endocrinologist, but there are many other options. The first thing is to do an evaluation and figure out the cause of infertility. If the tubes are truly blocked, IVF is the indicated therapy (surgery to fix damaged tubes is rarely effective, and when it does work, there is a significant risk of a subsequent pregnancy implanting in the tube instead of the uterus (so called “ectopic” pregnancy.) For women with subtle tubal issues, just doing the diagnostic test called a hysterosalpingogram (to see if the tubes are open) flushes mucous or other debris from the tubes; data suggests fertility is elevated the month following this test. For a subtle male issue, sometimes an intrauterine insemination (IUI) is all that is needed to make the difference. For women who are not ovulating, there are several oral medications we can give to help foster development of a follicle (the house for the egg). Either clomiphene citrate (Clomid) or Letrozole can be used. Women can then conceive with intercourse at home, or with an IUI if needed. Sometimes there is an underlying reason that ovulation is not occurring; in that instance, we can often times treat the underlying abnormality (sometimes a thyroid or pituitary issue) to restore normal cycles.

In what situations should a woman consider freezing her eggs? What does the process entail?

Any woman who might be treated with medication like chemotherapy for cancer or who have medical illnesses where “gonadotoxic” medications are a treatment, like lupus, should consider freezing eggs BEFORE they are exposed to these medications. In general, I think women in their 20s should learn about what egg freezing is, but not move forward with it given that they are very likely to meet someone by their early 30s and start a family. In the 30s it starts to make more sense, because in the early 30s success is still very good (in terms of live-birth chances per egg) and there is a significant decrease from the early to the late 30s in terms of efficiency of the process (the eggs start to become much more abnormal in the later 30s). We can still freeze eggs up to age 44, but a patient would have to freeze many more eggs to have a good chance of success at those ages. You also get fewer eggs from ovarian stimulation with advancing age. Essentially egg freezing is going through half of an IVF cycle: ovarian stimulation and egg retrieval (a process that takes ~ 10 days), but then the eggs are frozen instead of fertilized. For patients coming back to use their eggs, they are then thawed, fertilized, become embryos, and are transferred back to the patient’s uterus on day 3 or day 5 of life.

I thought the point you brought up regarding temporarily decreased AMH levels after stopping birth control pills was a really interesting fact that anyone considering freezing their eggs would want to know.

Yes, AMH is an excellent test for ovarian reserve, but it is not perfect. Available literature would suggest that hormonal contraceptive treatment does not affect ovarian reserve, but does affect our ability to have a read-out on the reserve. AMH levels are suppressed by as much as 50% on the birth control pill (and should return back to their “true” levels 2-6 months after coming off)

Are there any other issues you are aware of with the pill impacting fertility?

No. Very good evidence exists that the pill does not affect fertility, besides when you’re on it that you don’t get pregnant. After you come off the pill, it can take 1-3 months to return to your normal cycle. More than 3 months is abnormal and other causes for not getting your period should be evaluated. Anyone thinking about getting pregnant 1 year after coming off contraception should avoid depo-provera injections; it can take as long as 12-18 months to return to a normal cycle after completing a course of depo.

How soon before trying to conceive should a woman stop taking birth control pills?

1 month should be sufficient. That being said, many women who miss a pill or two during the cycle wind up conceiving, and there is no evidence that these pregnancies are in any way unhealthy or less viable.

What is the average time it takes for cycles to return to normal after discontinuing the pill?

Most women should have their cycle back to normal 8 weeks after coming off the pill.

What should you do if cycles don’t resume after this time?

A hormonal evaluation would be initiated if a woman didn’t get her period 3 months after coming off the pill. The most common cause of “secondary amenorrhea” (meaning someone who used to get their period but then stops) is actually pregnancy, so a pregnancy test is important in this context. Otherwise thyroid and prolactin hormones should be assessed, as well as potentially an assessment of the ovarian reserve (to screen for a condition called premature ovarian insufficiency).

Is there anything couples can do to increase their chances of getting pregnant (for example, is it necessary to cut out caffeine or alcohol)?

Yes, absolutely. Data would suggest that obesity is associated with 2 times longer time period to conceive, and underweight patients 4 times longer; having a normal body weight, while sometimes tough to achieve, is definitely desirable for fertility. More than 5 hours of vigorous exercise per week has also been associated with a reduction in fertility, since over-exercising can affect the health and length of the menstrual cycle. Smoking adversely affects fertility and increases the risk of ectopic pregnancies; more than 2 alcoholic drinks per day in women is associated with an increase in infertility. Caffeine isn’t associated with infertility, but is associated with an increased risk of miscarriages. We recommend limiting intake to 250mg/day of caffeine or less.

Dr. Reichman’s office is at 40 Worth Street in Tribeca. His office phone number is 646.962.7499.